Quality and safety

Summary

Quality in healthcare is the measure of the best possible outcomes in patient-centered care under the circumstances and with the resources available. Safety is a central dimension of quality in healthcare. It is the measure of standards that keep patients and healthcare workers free from hazards and harm due to error, management, or environmental factors and maintain the risk of harmful incidents as low as possible. While it is the responsibility of every healthcare professional to provide patients with safe healthcare that meets the applicable standards of quality, absolute safety can never be achieved. Therefore, the aim of patient safety is to reduce the risk of harm to the lowest acceptable level. The greatest risk factor in patient safety is human error, which can be defined as the accidental failure to perform an action as intended (e.g., misdosing the appropriate drug) or accidentally performing the incorrect action (e.g., prescribing the wrong drug). Errors can be acts of commission (e.g., amputation of the wrong limb) or omission (e.g., failure to amputate a necrotic limb).The deliberate deviation from standards, laws, or rules constitutes a healthcare violation. Human factors (e.g., poor communication, inappropriate performance), system factors (e.g., a mismatch between resources and workload), and external factors (e.g., legislation, weather, any factor beyond the control of the organization) all play a role in the development of safety risks. While medical errors and violations are committed by individuals, flaws in the system, i.e., systemic errors, increase the risk of harm and hazards due to medical error and violations. Therefore, error mitigation is most effective if the focus lies on eliminating errors on a systemic level rather than identifying and disciplining the individuals responsible.If an error has occurred, physicians must immediately inform the patient, disclose the nature of the error, and implement corrective measures to minimize patient harm.

Medical error analyses aim to identify, either retrospectively (root cause analysis) or prospectively (failure mode and effects analysis), risks in a healthcare system that may lead to hazards, errors, violations, and harm. Quality improvement (QI) in healthcare aims to implement system-based improvements in order to minimize the incidence and prevent the recurrence of medical errors. The “plan, do, study, act”-cycle (PDSA cycle) is a QI tool commonly used to identify areas that require improvement. Quality control employs tools such as run charts and Shewhart charts to assess the impact of measures introduced to improve quality and safety. Human factors design aims to minimize the potential for error by employing strategies such as forcing functions, standardization, and simplification based on psychological and physiological principles to design tools and processes that maximize compatibility between humans and the equipment/environment they interact with.

​​​​​​​Definitions

Adverse reaction: an unintended, unexpected, or undesirable consequence of a correct and justified action

Adverse drug reaction: an adverse reaction in response to the administration of a drug

Adverse event: any harm resulting from medical management rather than an underlying disease.

Accidental failure to perform an action as intended (e.g., misdosing the appropriate drug) or accidentally performing the incorrect action (e.g., prescribing the wrong drug), which could potentially result in harm to the patient.

Omission: failure to perform the appropriate action when required (e.g., failure to note a history of allergies, leading to the administration of a drug against which the patient has a known allergy)

Individual error: medical error resulting from the failure of a single healthcare professional due to negligence

Systems error: medical error resulting from a series of actions and/or factors in treatment or diagnosis, from flaws in technical and organizational design and/or decision-making, and from failure to recognize and mitigate hazards and risks in the healthcare setting

Negligence: failure to perform an action with the skill, care, and knowledge expected of a healthcare provider under reasonable circumstances

Negligent conduct on the part of a healthcare provider or performance of a medical task with unreasonable lack of skill.

In medical law: the judicial determination that negligent or willful misconduct in failing to adhere to current established standards of care has resulted in harm to the patient and legal liability of the healthcare provider responsible.

Patient safety: healthcare that keeps patients free from harm and hazards and reduces the risk of harmful incidents to an acceptable minimum

Safety culture: : a culture that promotes safety awareness, develops and implements measures for the maintenance of a safe work environment and ensures that individuals can openly express safety concerns.

The Swiss cheese model illustrates how any safety system (slice of cheese) will have flaws (holes), either due to active failure or latent conditions, that allow errors or hazards to pass through safeguards and cause harm.

A multilayered safety system; (multiple slices of cheese) reducesthe risk of error and harm by ensuring that if a hazard manages to pass through a hole in one layer, a subsequent layer will likely block its further passage through the system.

When the flaws in the individual layers align, a hazard or error can result in harm.

Definition: The design and engineering of equipment, systems, processes, methods, and environments to fit the individuals who interact with them with the goal of reducing error while improving efficiency, productivity, safety, and comfort.

Incompatibilities between health care personnel and the equipment they use, constitute a patient safety risk/hazard.

Safety risks can be minimized by:

Forcing functions

Equipment, process, method, or system design features that prevent error by forcing the best option by default.

Most effective technique for minimizing adverse events, as it inhibits a chain of action that cause or perpetuate error.

Examples:

Anesthesia gas cylinders with gas-specific nozzles for different gases

Software that prevents incorrect dosages of drugs and warns the user of potential adverse reactions or interactions.

Avoiding shared storage of drugs with similar labels or names

Standardization

The development and implementation of standards that apply to various aspects of a process or system in order to improve reliability, efficiency, communication, and safety.

Examples:

Standardized protocols and guidelines: help ensure a consistent level of quality and increase efficiency

Measures of health care quality allow us to compare the performance of individuals and hospitals at a particular point in time as well as an improvement or deterioration in the quality of health care over a period of time.

Measures reported on the hospital website or in a brochure inform consumers about the level and quality of healthcare that they can expect from a healthcare facility

Run charts are used in healthcare quality improvement, for example, to analyze the impact of an intervention over time and to help determine whether the improvement is a random or a true trend.

Convenience sampling: a study population that is drawn from a population that is easy to reach. Since the study population is not chosen at random, this type of study can lead to bias and may not be as effective as a randomized control trial.

Quality improvement is a continuous process of prospectively and retrospectively reviewing measures of quality control and maintenance to progressively improve the standard of healthcare and prevent medical error.

Models to improve healthcare quality

Plan: Define an area that needs improvement and plan potential interventions or innovations to bring about a corrective change.

Do: Test the new intervention.

Study: Assess the impact of the intervention on quality of healthcare.

Act: Implement the new intervention if the previous test showed a positive impact on healthcare quality or restart the cycle if the results were negative or negative.

Lean process improvement: the process of continually evaluating the methods used to identify and eliminate factors that use time, energy, and resources without improving patient outcome (e.g., avoiding unnecessary investigations)